Standards of medical care in diabetes all over the world - Research Paper Example

?Health Policy Analysis Problem ment Diabetes mellitus, particularly type 2, is a disease with a high incidence and prevalence in the population. It leads to serious and potentially preventable complications, and currently incurs massive economic costs. Despite great advances in the medical community enabling thorough understanding of the natural history of the disease and despite the development of drugs, interventions, and clinical guidelines, diabetes continues to be a rampant disease. Background Diabetes mellitus is a disease characterized by high levels of sugar in the blood, which may be due to the insufficient production of insulin by the pancreas, resistance to insulin, or both. Risk factors for developing diabetes, particularly type 2 diabetes, include obesity, a sedentary lifestyle, heart disease, and other medical conditions. Persistently high levels of blood sugar can lead to many complications, most of which can lead to the deterioration of function and quality of life, affecting family members and the community. The Centers for Disease Control and Prevention (2011) lists the complications of diabetes in the United States. Adults with diabetes are 2-4 times more likely to have heart disease and develop stroke, leading to further deterioration. Diabetes is also the leading cause of blindness among adults aged 20-74 years old, and the leading cause of kidney failure, which can proceed to chronic dialysis or kidney transplant. More than half of patients with diabetes have varying forms of nervous system damage, presenting as impaired sensation, slowed digestion, erectile dysfunction, and other nerve problems. More than half of non-traumatic amputations in the United States are performed among diabetics. It is also a cause of gum disease, pregnancy complications, functional deterioration, and depression. It is currently the seventh leading cause of death in the United States. Diabetes, apart from being a debilitating disease, is also a serious public health concern, as it consumes billions of dollars each year. Centers for Disease Control and Prevention (2011) estimate that presently, diabetes affects 25.8 million people in the United States, which makes 8.3% of the population. Medical costs in 2007 for diabetic patients amounted to $116 billion. Further costs from disability, loss of work, and premature mortality amounted to $58 billion, which made up a total of $174 billion in direct and indirect costs of diabetes. In a cross-sectional study done by the Centers for Disease Control and Prevention in 2008, the prevalence of diabetes among adults in the United States was found to have marked sociodemographic disparities. Particularly prone to having diagnosed diabetes are members of racial or ethnic minorities, those with lower educational attainment, and those who were poor (Beckles, Zhu, and Moonesinghe, 2011). This signifies that access to health care is a major determinant in diabetes morbidity, and a health policy should focus on the mentioned vulnerable or high risk groups. A comprehensive health policy should include interventions specifically for the high risk groups, and should include health promotion and risk reduction efforts. Diabetes formerly used to primarily affect adults. However, with the rise of childhood obesity, more children now are developing type 2 diabetes. Furthermore, early onset type 2 diabetes was found to be associated with an increased risk of morbidity and mortality during the most productive years of life. The progression from prediabetes to type 2 diabetes was notably quicker, taking only an average of 21 months, versus 5-10 years in adults (D’Adamo and Caprio, 2011). This signifies the need for early interventions and a focus on reduction of risk factors. Type 2 diabetes, while devastating both in the individual and national levels, is potentially preventable and treatable. It is well-researched and well-documented, with many updated clinical practice guidelines and registries available and accessible. The challenge, thus, for a health policy is in instituting prevention measures at all levels, and for ensuring continuity of care for those already with the disease. Landscape Identification Diabetes type 2 is a complex, chronic, and progressive disease with various stages and points of prevention and treatment. It affects people’s functionality, thus affecting the community, and the national economy as well. Stakeholders thus include the following: 1. Populations at risk, with special consideration of vulnerable groups, 2. People already diagnosed with the disease and those already suffering from its complications, 3. Family members or caregivers of the patients, 4. Health care providers, including health care staff, medical communities, insurance companies, and institutions, and 5. Policy makers and tax payers. Certain factors can affect whether a policy or program will be successful or not. First, elements of a policy must be grounded on evidence-based research. It must, for example, make use of screening procedures that have undergone trials and have been found to be accurate. A probably good choice is to tailor the medical aspects of the policy, from preventive measures and early detection to therapeutics and management of complications, to an existing and updated clinical practice guideline. The World Health Organization (2006) and the American Diabetes Association (2010), among others, provide such a guideline. Basing a policy on evidence-based research benefits all stakeholders. Clinical practice guidelines, such as those released by the American Diabetes Association (2010), have recommendations regarding the disease from early detection, screening procedures, management, and follow-up. It assures patients that they are being subjected to at least standard medical care, it guides health professionals on how to approach cases and helps them provide standard medical care for all patients, and it gives policymakers and insurance companies sound science on which to base their policies and programs. A possible caveat in depending on such guidelines, however, would be overlooking the needs of the vulnerable groups. Most practice guidelines tend to underrepresent vulnerable groups such as racial and ethnic minorities, and populations with special needs such as pregnant women and pediatric patients. It is thus important to keep the vulnerable groups in mind when formulating policies, as neglecting vulnerable groups further increase the disparities in health care acquisition. Another important factor in the success of a health policy is participation, especially empowerment of populations at risk and those already with the disease. This includes, but is not limited to, educational programs, healthy lifestyle interventions, and participation in setting out goals. Diabetes education regarding self-management seems to be the cornerstone of this approach. It has been found that such an approach is effective in improving clinical outcomes and overall quality of life, it makes scientific research and guidelines more relatable and accessible to the most number of people, and it is quite sustainable and effective in maintaining self-management behaviors (Funnell et al., 2009). This approach may work best with patients and family members, as it gives them more power regarding their conditions. It can be quite troublesome for policy makers and financiers, because it has been found that there is no single best educational program. Various people have various learning strategies, thus, a policy based on participation and patient education must be flexible. There could then be problems in implementation, financing, and progress checks. Quality management is also an important factor in health programs. A locale must have the manpower to support a program, which means existing health care providers must be of good skills and training. There should also be ongoing efforts in producing highly skilled staff, not limited to physicians, nurses, and other hospital personnel. Availability and accessibility of options must also be taken into consideration. All stakeholders must reach a compromise regarding options wherein the benefit is for the most number of people, and also the most cost-effective. An example is in screening for diabetes. First, a health policy must determine who to screen for diabetes. Current guidelines recommend screening asymptomatic individuals with certain risk factors such as a body mass index of 25 kg/m2 or greater, physical inactivity, a first-degree relative with diabetes, and others (American Diabetes Association, 2010). Second, a policy should decide on which screening method to use. For many years, the diagnosis of diabetes has been based on plasma glucose, either by obtaining a fasting plasma glucose, or doing an oral glucose tolerance test. In their latest released guideline, the American Diabetes Association (2010) recommended the use of glycosylated hemoglobin as part of the criteria for diagnosis. While more data may be obtained from glycosylated hemoglobin than from plasma glucose alone, its cost-effectiveness should be analyzed further. It may not be accessible to certain populations, which can lead to health care disparities. This is an example wherein certain stakeholders, such as populations at risk and patients diagnosed but with no complications yet, would benefit from an option, but other stakeholders, such as taxpayers and policymakers, would not find cost-effective. Lastly, evaluation and having indicators of success of any policy should benefit all stakeholders. Populations at risk and patients are assured that they are obtaining proper care, health care providers see the results of their efforts, and policymakers can gauge the success and failures of the program and do the necessary adjustments. Alternatives Considering the natural history of diabetes, a health policy regarding it should be broadly encompassing. Three alternatives are presented here. Alternative 1: Diabetes Self-Management Education and Training The first alternative focuses on early detection and prevention at all levels. In the natural history of diabetes, there are three points for prevention: primary, which is before the onset of the disease; secondary, which is before the onset of complications; and tertiary, which is to prevent further deterioration and loss of functionality. In this alternative, the goal is to prevent the onset of diabetes and its complications. This can be achieved by the individual by making healthy lifestyle changes, comprised of a good diet and adequate physical activity, and by being committed to a pre-diabetes therapeutic regimen, if required. In a larger scale, a policy devoted to these goals would focus on educational and training programs, and the acquisition of means to carry out early detection strategies. Such a policy would first require qualified educators who would teach the target audience about diabetes self-management. Educational programs would include such topics as: general awareness on diabetes, its risk factors and complications; lifestyle changes that can decrease the probability of its onset; and coping with diabetes-related problems. Hand-in-hand with education would be early detection. Populations at risk should be screened for diabetes, using plasma glucose or glycosylated hemoglobin. Aggressive treatment and lifestyle interventions should then be enforced for those found with impaired values. Marrerro (2009) summarizes three major clinical trials that have demonstrated the benefits of lifestyle interventions, which is the core of the educational programs proposed in this alternative. The clinical trials, done in China, Finland, and England, demonstrated a 41% to 58% reduction in risk of developing diabetes after lifestyle interventions alone. In a review done by Boren et al. (2009), data presented showed that adopting a similar education and management program reduced the medical costs of gestational diabetes by an average of $13,000 per pregnancy. The same program reduced the Medicare costs of individuals who complete the diabetes education and management program by $135 per patient per month, and inpatient hospital costs by $160 per patient per month. Furthermore, it was found that lifestyle intervention techniques reduced the incidence of diabetes by 58% among 3200 overweight or obese prediabetes adults. Smith et al. (2010) did a cost-effectiveness analysis of a diabetes prevention program similar to that proposed in this alternative. Done in a community setting, the program reduced the relative risk of metabolic syndrome by 16.2% and yielded a life expectancy gain of 3.67 days after a 12-month follow-up. The cost was $3420 per quality-adjusted life years gained. In a society like the United States where much weight is given to personal responsibility, such a program should not be difficult to impose. It requires little from state funding and places the success mostly in the hands of the participants. It is also very timely with the continuing epidemic of obesity and physical inactivity. Its targeted impact is very large considering the cost, as shown in previous cost-effectiveness analyses. Possible drawbacks to watch out for in this alternative are the sudden surge of newly diagnosed diabetics and the inability of the existing health care system to cope with this. It also does not address the current inadequate level of diabetes care and the gaps in continuity of care. Alternative 2: Diabetes Control Program This alternative focuses on improving the quality of existing diabetes health care and making it more accessible to more people, including members of vulnerable groups. It can be argued that at present, the magnitude of the diabetes epidemic it too big, with a relative lack of funding being devoted to it. Hence, it may not be practical at this point to focus on primary prevention. Primary prevention alone can bring about an onslaught of new cases that can overwhelm the health care system and compromise the quality and continuity of care among those already diagnosed with the disease. This alternative thus proposes a more timely diabetes control program, wherein the focus is on building up on already existing programs and practices and making it more accessible and affordable for the most number of people. This approach mainly benefits patients who are already diagnosed with diabetes and health care workers as it allows them to be more efficient and effective in dealing with diabetes cases. With this approach, the target is to improve health outcomes of patients and decrease the burden of the disease. In order to do this, first, a systematic database should be in place. This is to guide epidemiologists and health personnel in defining the scope of the problem, identifying gaps in care, and developing intervention projects. Next, effort and funding must be put in training health care professionals so that they are equipped with updated evidence-based knowledge and training. Funding should also be given in improving medical infrastructure, which intends to make out-patient visits, laboratory work, and drug dispensing efficient. Relevant, evidence-based diagnostics and medicines should also be affordable and accessible. In a similar protocol, the Diabetes Care Protocol (Cleveringa et al., 2010), researchers assessed the cost-effectiveness of an approach that offered more quality service specifically for a diabetic patient, compared to usual care. The group looked at health outcomes such as glycosylated hemoglobin, blood pressure, cholesterol panel, and existence of complications after one year. There was a decrease in coronary heart disease risk among the patients, with a corresponding reduction by €517 for costs for CHD complications. Cost-effectiveness analysis showed the cost was €38,243 per QALY gained. Implementing this program would require a strong political will, as this approach significantly needs a huge funding. However, it is equitable in that it aims to give care to those who need it most and its proposed solutions are most congruent with the present state of the problem. Alternative 3: Chronic Care Model This alternative approaches the problem of diabetes more holistically. Its focus is on improving health in general and reducing the incidence and impact of diabetes and other chronic diseases. According to the Department of Health and Families (2009), chronic diseases are characterized the by the following: they cause the greatest burden of disease in developed countries, such as the United States; they are preventable, share common risk factors, and have complex causes; they have a gradual onset but are long term and persistent; they become more prevalent with age although they occur through the life cycle; and though not usually immediately life threatening, they can compromise quality of life through physical limitations and disability. Understanding these about chronic diseases is central in planning and implementing this alternative. Under the framework of chronic disease care, this alternative aims to tackle the problem of diabetes by involving the patient and family members, implementing prevention at all levels, providing interventions across the entire continuum of care, and working within the capacity of the community. Dennis et al. (2008) looked at the Chronic Care Model and did an analysis of 141 studies and 23 systematic reviews across seven countries, including the United States. Their review found that self-management interventions improve patient outcomes and the process of care. Like in any program or approach that has self-management as a cornerstone, health personnel should have the training to provide effective self-management support to patients. An extra step should be taken, wherein self-management efforts is incorporated into patient education and into clinical practice guidelines, to ensure that counsel being given to patients are evidence-based, consistent, and adequate. Interventions to delivery-system design should also be done. Multidisciplinary team care, for example, has been shown to have positive effects on patient outcomes and the behaviors of health care providers. Stakeholders should invest on finding out what delivery-system design works best for a specific locale and take measures to implement it. No studies yet can be found on cost-effectiveness of a similar program. However, advocates of the chronic care model, such as the European Observatory on Health Systems and Policies (Busse et al., 2010) have provided information on the cost per QALY saved by interventions to reduce or prevent obesity, the major culprit in most chronic diseases. School-based interventions to improve nutrition and increase physical activity were estimated to cost $4,305 per QALY gained. Diet, exercise, and behavior modification cost $12,460 per QALY gained. Overall, this alternative aims to reform the way health care, especially regarding chronic diseases, is delivered. It aims to improve general understanding about diabetes, promote healthy lifestyles, reduce risk factors, and improve on the quality and accessibility of health care. If this is to be done, it would require great political commitment and community participation. The following tables summarize the three alternatives. Table 1. Description of alternatives DESCRIPTION Alternative 1 - Diabetes Self-Management Education and Training Alternative 2 - Diabetes Control Program Alternative 3 - Chronic Care Model Focus Early detection and prevention at all levels Increase access to and quality of diabetes health care Improve health by reducing the incidence and impact of chronic conditions, including diabetes Stakeholders that will benefit the most Populations at risk Patients already diagnosed with the disease Family members and relatives Health care workers Patients already diagnosed with the disease Health care workers Populations at risk Patients already diagnosed with the disease Family members and relatives Health care workers Policymakers Aims Prevent onset of diabetes and its complications Improve on quality of health care for diabetics Make health care and medicines more affordable and accessible to more people Provide continuity of care for diagnosed diabetics Improve general understanding about diabetes and other chronic diseases Promote healthy lifestyles Improve on quality and accessibility of health care Targeted outcomes Decreased incidence of diabetes Decreased incidence of complications Improve health outcomes Decrease the burden of diabetes Improve overall health of the community Improve health professional performance Improve patient disease control Components Education and training programs at all levels of prevention Early detection by screening populations at risk Database or registry Improvements in quality of health care personnel Improvements in infrastructure Self-management support Delivery system design Decision support Clinical information systems Resources needed Educators Health personnel Educational programs – facilities, materials Screening test – materials, personnel, facilities Funding Health personnel Epidemiologists Infrastructure Affordable diagnostics and medicines Up-to-date guidelines on diabetes management Funding Educators Health personnel Up-to-date guidelines on diabetes and other chronic diseases Estimated monetary gains Reduction by $13,000 per pregnancy, $135 per outpatient per month, $160 per inpatient per month Reduction by €517 of costs for CHD complications No studies yet Possible drawbacks Surge in newly diagnosed patients might overwhelm the health care system Continuity of care might be lacking Difficulty in procuring funding Controls the epidemic but does not prevent it Requires more intense and long-term commitment from all stakeholders Table 2. Analysis of alternatives CRITERIA Alternative 1 - Diabetes Self-Management Education and Training Alternative 2 - Diabetes Control Program Alternative 3 - Chronic Care Model Cost-benefit $3,420 per QALY gained €38,243 per QALY gained Educational interventions: $4,305 per QALY gained Lifestyle interventions: $12,460 per QALY Political feasibility Can easily be done if all stakeholders agree on common goals Need strong political will in order to get approval and funding from those not directly involved Need strong political will and community participation Ethics/Equity Participants have the bigger share of responsibility in having a successful outcome Special attention must be given to vulnerable groups so it does not become dominated by a certain socioeconomic group Provides care to those most in need of it May overlook a vast majority of populations at risk and vulnerable groups Provides care across all continuums Administrative feasibility Difficulty will mostly be in training and hiring staff Difficulty in procuring funds and building infrastructures Requires similarity of goals and community participation Timeliness Addresses epidemic of obesity and physical inactivity Proposed solutions correspond most with the current state of the problem Addresses epidemic of preventable chronic diseases and the burden of these diseases Recommendation The current state of the problem on diabetes in the country calls for a policy that approaches it holistically. While the ever-growing epidemic of obesity and physical inactivity contribute to the increasing incidence of diabetes, those already diagnosed and already suffering from the complications continue to struggle to attain quality health care and continuity of care. Thus, solutions must be made all throughout the continuum of the sickness, from prevention at all levels to treatment and management. The recommended policy that can cover all these concerns is the chronic care model. Most of its benefits over the other alternatives are already described above. Under the chronic care model, prevention and early identification is given significance. Healthy eating habits, adequate physical activity, and healthy lifestyle choices such as nonsmoking all contribute to reduction of risk factors for chronic diseases. These concepts can be taught in the school and in the community and have great impact on individual and public health. Prevention and early identification should go hand-in-hand. A further rationale for diabetes screening under the chronic care model is the fact that it is a risk factor for other chronic diseases such as cardiovascular disease. However, one of the dangers of a purely preventive model, as Narayan, Chan, and Mohan (2011) pointed out, is that it could increase the workload of the health system due to the deluge of newly diagnosed patients. They thus recommend that policies also have provisions for improving the existing health care. This is addressed in the chronic care model. Another aspect of the chronic care model which could likely lead to its success is its dependence on community capacity. A case study on managing diabetes at the community level (Ingram, Gallegos, and Elenes, 2005) showed that success was likely with a good partnership among providers, community-based classes, having a trusted link to the participants, linking diabetes community interventions and clinical care, and regular program evaluations. The chronic care model, with its aim towards health reform suitable to the community, works towards these examples. Implementation Strategy The following are the strategic supports that will enable the interventions of the chosen alternative to be effectively implemented: a positive policy environment, adequate resources, a yielding health system, a systematic delivery system, decision support, continuing information about diabetes, and community capacity. In order to obtain a positive policy environment, which means making the policy acceptable and favorable to all stakeholders, some steps must be taken. First, all stakeholders must arrive at a consensus and commitment to fully support the policy. Communication and collaboration among the different sectors must be strengthened. Public awareness regarding diabetes and other related chronic conditions must be increased, and as much as possible, this alternative must be integrated with other policies across the health and government sectors. Adequate and appropriate resources must be secured for the alternative to be successful. This includes adequate advocacy, consistent financing, and allocations for populations with high need. Infrastructure should also be invested on and existing resources should always be optimized. There should also be some reform on the health system. It should maximize available resources and obtain the favor of all stakeholders by providing safe and quality care, increasing emphasis on prevention, focusing on the needs of vulnerable groups, focusing on community based care and self-management, and strengthening partnerships and coordination between the patients, the health providers, and the public. A delivery system design assures that teams working towards carrying out the policy’s aims are delivering their services in a systematic, efficient, and effective way. This can be achieved by having an integrated planning, providing multidisciplinary care, supporting self-management and prevention, being culturally competent, and having quality education and training. A decision support assures stakeholders that clinical care is consistent with updated and evidence-based research. In line with this, information, communication, and disease management systems ensure that everyone has sufficient knowledge about diabetes and can do their part in managing it. Aside from clinicians, patients and other stakeholders should also be able to access usable and understandable information. Lastly, the capacity of the community to undertake the fulfillment of the chosen policy’s interventions must be ascertained. Clinicians must be highly qualified, and educators must demonstrate capability. Implementation Planning In implementing the chronic care model alternative, the following elements of care must be provided across all population groups and settings. Under primary prevention, the focus is on prevention of risk factors among the well population. In secondary prevention, the focus is on early detection. Early detection can be done among targeted populations, such as those with increased risk for diabetes. The population can also be stratified according to risk and disease severity, as this streamlines care and results in better health outcomes for those diagnosed. Tertiary prevention focuses on reducing the consequences of the disease. This can be most effectively done with multidisciplinary and individualized care. The specific needs of the person must be assessed, a practical care plan must be made, and regular monitoring and review must be done. At all times, individuals must be managed based on evidence-based recommendations. Individuals would also have better outcomes if health care providers offer support for self-management. There should also be provisions for rehabilitation and palliative care. Monitoring and evaluation throughout the entire life of the policy must be done. At the onset of the policy, there should be a schedule for reviewing and updating the action plan. The Australian Institute of Health and Welfare (2007) recommends the following indicators in monitoring the outcomes of policies directed towards addressing diabetes: 1. Prevalence of diabetes risk factors over time; 2. Proportion of those identified at risk and those taking action to reduce their risk; 3. Proportion of those being opportunistically screened and those being appropriately screened; 4. Number and characteristics of diabetes programs, initiatives, and services; 5. Accessibility and cultural suitability of services; 6. Number and characteristics of diabetes identified; 7. Proportion of diabetes patients with annual care; 8. Proportion of people with diabetes who meet guideline targets for glycosylated hemoglobin and other clinical parameters; 9. Diabetes-related death over time; 10. Quality of life of people with diabetes; and 11. Prevalence and incidence of diabetes, its complications and comorbidities over time. The alternative should be assessed at least yearly using these indicators and appropriate adjustments should be made. References American Diabetes Association. (2010). Standards of medical care in diabetes – 2010. Diabetes Care, 33(S1), S11-S61. Australian Institute of Health and Welfare. (2007). National indicators for monitoring diabetes: report of the diabetes indicators review subcommittee of the national diabetes data working group. Canberra: AIHW. Beckles, G. L.., Zhu, J., & Moonesinghe, R. (2011). Diabetes – United States, 2004 and 2008. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report, 60, 90-93. Retrieved from http://www.cdc.gov/mmwr/pdf/other/su6001.pdf. Boren, S. A., Fitzner, K. A., Panhalkar, P. S., and Specker, J. E. (2009). Costs and benefits associated with diabetes education: a review of the literature. The Diabetes Educator, 35(1), 72-96. Busse, R., Blumel, M., Scheller-Kreinsen, D., and Zentner, A. (2010). Tackling chronic disease in Europe: strategies, interventions, and challenges. United Kingdom: World Health Organization. Centers for Disease Control and Prevention (2011). National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention. Cleveringa, F.G.W. et al. (2010). Cost-effectiveness of the Diabetes Care Protocol, a multifaceted computerized decision support diabetes management intervention that reduces cardiovascular risk. Diabetes Care, 33(2), 258-263. D’Adamo, E. & Caprio, S. (2011). Type 2 diabetes in youth: epidemiology and pathophysiology. Diabetes Care, 34(S2), S161-S165. Dennis, S.M. et al. (2008). Chronic disease management in primary care: from evidence to policy. Medical Journal Australia, 188, S53-S56. Department of Health and Families. (2009). Northern Territory Chronic Conditions Prevention and Management Strategy 2010-2020. Northern Territory. Funnell, M. M. et al. (2009). National standards for diabetes self-management education. Diabetes Care, 32(S1), S87-S94. Ingram, M., Gallegos, G., and Elenes, J. (2005). Diabetes is a community issue: the critical elements of a successful outreach and education model on the U.S.-Mexico border. Preventing Chronic Disease Public Health Research, Practice and Policy, 2(1), 1-9. Marrerro, D. G. (2009). The prevention of type 2 diabetes: an overview. Journal of Diabetes Science and Technology, 3(4), 756-760. Narayan, V., Chan, J., & Mohan, V. (2011). Early identification of type 2 diabetes: policy should be aligned with health systems strengthening. Diabetes Care, 34(1), 244-246. Smith, K. J. et al. (2010). Cost-effectiveness analysis of efforts to reduce risk of type 2 diabetes and cardiovascular disease in Southwestern Pennsylvania , 2005-2007. Preventing Chronic Disease, 7(5), A109. World Health Organization (2006). Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia: report of a WHO/IDF consultation. Geneva, Switzerland: WHO Press. Read More